Upper Extremity Diagnostic Socket Order Form
(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name
*
Side
*
Please Select
Right
Left
Bilateral
Height
Weight
*
Age
Sex
Please Select
Male
Female
Non-binary
Activity Level
Please Select
Minimal
Moderate
High
Heavy Duty
Practitioner
*
Facility & Location
*
Clinic Name and City
Phone/Email
Enter preferred contact method
Ship to Address
*
Enter the address the finished socket should be shipped to
Date Ordered
/
Month
/
Day
Year
Date
Requested Date Needed
/
Month
/
Day
Year
Date
PO
Enter a PO if you would like, this is for your records.
Measurements
Please enter all pertinent measurements
Chest Circumference
Sound Side Arm Circumference - Axilla
Sound Side Arm Circumference - Epicondyles
Sound Side Arm Circumference - Mid-Forearm
Sound Side Arm Circumference - Radial Styloid
Sound Side Arm Circumference - Metacarpals
Amputated Arm Circumference - Axilla
Transhumeral only
Amputated Arm Circumference - Mid-Humerus
Transhumeral only
Amputated Arm Circumference - Distal End
Transhumeral only
Amputated Arm Circumference - Axilla
Transradial only
Amputated Arm Circumference - Cubital Fold Arm
Transradial only
Amputated Arm Circumference - Cubital Fold Forearm
Transradial only
Amputated Arm Circumference - Mid-Forearm
Transradial only
Amputated Arm Circumference - Distal End
Transradial only
Sound Side Arm Length - Acromion to Epicondyle
Sound Side Arm Length - Epicondyle to Thumb Tip
Sound Side Arm Length - Axilla to Epicondyle
Sound Side Arm Length - Epicondyle to Radial Styloid
Sound Side Arm Length - Styloid to Thumb Tip
Sound Side Arm Length - Wrist to Thumb Tip
Amputated Arm Length - Acromion to Distal End
Transhumeral only
Amputated Arm Length - Axilla to Distal End
Transhumeral only
Amputated Arm Length - Axilla to Cubital Fold
Amputated Arm Length - Cubital Fold to Distal End
Socket Specifications
Model Type
Please Select
Cast without modifications
Cast with modifications
Positive model without modifications
Positive model with modifications
Diagnostic socket without modifications
Diagnostic socket with modifications
Select type of cast/model that is being sent to WML. If any modifications or change to alignment is needed, please enter that in the Modification Notes section.
Type of Amputation
Enter type of amputation/socket (i.e. transradial, ED, transhumeral, SD, etc.)
Power Source
Enter power source for prosthesis (i.e. body-powered, external powered, etc.)
Suspension
Enter suspension method for prosthesis (i.e. anatomical, locking, suction, etc)
Modification Notes
Enter any pertinent details or requests for modification. If the model sent to WML is already modified, please select a "with modifications" option in the Model Type question and enter "Already modified" in this section.
Socket Design
Socket Design
Please enter a detailed prescription of the prosthesis design below (i.e. windows, trimlines, inserts, pads, locks, valves, etc.)
Diagnostic Socket Info
Socket Set Up
*
Please Select
Diagnostic socket only
Diagnostic socket with distal attachment
Diagnostic socket with distal attachment and componentry
Other, specify in Notes section
Select option for how you would like the laminated socket to be finished and sent to you. If an attachment block and/or componentry is selected, please enter desired alignment below or note that alignment lines are drawn on the model provided.
Plastic Type
Please Select
Vivak PETG
CoPoly
Thermolyn
ProComp Carbon
Other, specify in Notes section
Select type of plastic for diagnostic socket. If left blank, VivakPETG will be used.
Plastic Thickness
Please Select
WML choice
3/16"
1/4"
3/8"
1/2" / 12-13mm
5/8" / 15-16mm
Select thickness of plastic for diagnostic socket. If left blank, WML will decide thickness based on size and activity level.
Vacuum Forming Method
Please Select
Drape
Bubble/Blister
Select vacuum forming method. If left blank, model will be bubble/blister formed.
Flexible Inner
Please Select
None
Pe-Lite
Bocklite
Northvane
Proflex
OPTEK Flex Comfort
ORFIT Trans
Other, specify in Notes section
Select socket insert material. If no socket insert is desired select none or leave blank.
Pulling Notes
Enter any pertinent information or requests for pulling the diagnostic socket.
Range of Motion
Forearm Flexion
Enter range of motion for amputated limb
Forearm Extension
Enter range of motion for amputated limb
Wrist Flexion
Enter range of motion for amputated limb
Wrist Extension
Enter range of motion for amputated limb
Ulnar Deviation
Enter range of motion for amputated limb
Radial Deviation
Enter range of motion for amputated limb
Components
This section can be left blank if you have chosen to receive just the socket.
Component Method
Please Select
Practitioner uses components from own office
Practitioner provides/ship components to WML
WML provides components.
Select manner in which components are provided for the diagnostic socket.
Terminal Device
Enter terminal device being used for prosthesis
Wrist Unit
Enter wrist unit being used for prosthesis
Prosthetic Elbow
Enter elbow being used for prosthesis (if applicable)
Additions
Hook-to-Hand Adapter
Standard Cable + Housing
Standard Cable + Teflon Housing
TRS Spectra Cable + Housing
Heavy Duty Cable + Housing
TRS Rapid Buckle Harness
Custom Triceps Pad
Fillauer Triceps Pad
ELF Strap
Figure 9 Harness
Figure 8 Harness
Notes
Notes
Enter any pertinent notes, information, or requests in this section.
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